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A five-year study of eclampsia in Maryland
(1) Lisa, .7. R., and Levine, J.: AI&. Path. 23: Xl, 1937. (3) Ocunn, T.: X~cv. Med. Del Rosario 21: 797, 1931. (:j) Perazzi, P.: Alt,i d. r. Scad. e fisiocrit. in Miena. 2: 335, 1927; also Zentmlbl. f. Gyniik. 51: 3Oti9, 1937. (a) Preis, K., arul Pore, A.: Wien klin. Wchnschr. 41: 235, 19% (5) Toe@, T.: J. A. M. A. 93: 32, 1929. (6) Rhamy, 33. w.: .J. h. M. A. 67: 405, 19%. (;j Lewis, IS., Gc~~olZ, G., and Stryker, G. V.: J. A. M. A. 94: 1987, 1930. (8) Junghans, E.: Monatschr. f. Geburtsh. u. Gyniik. 98: 193, 1934. (9) CorneEl, P. H.: Am. J. Path. 10: 519, 1934. (10) GardCer, S. 8.: Australian and New Zealand J. Surg. 4: 279, 1935. (11) Hussy, P. : Zentralbl. f. Gyniik. 59: till? 1938. (12) Cownsellor, V. S., and Hoernvr, M. T.: AIL J. Burg. 26: 374, 1934. (13) I:asteZZani, dldo: Fungi and Fungous Diseases, Chicago, 1928, Pub. A. M. A. pp. 203. (14) Hen&i, d. T. : Mold+ Yeasts and Aetinomycetes, New York, 1930, Pub. .Iohn Wiley SC Sons. i 1.i) C’crst~llani, .4Mo: Am. Med. 23: 289, 19%
:\ FIVE-YEAR J.
STUDY
MORRIS
&ESE,
OF ECLAMPSIA
IN NARYLAND
M.D.,
%ID.,
FR,ANK W. PEYTON, (Prom
the L)eprtment
of
Obstetrics,
IZALTIMORE,
M.D., LAFAYETTE, University of Illaryland,
AXD
Im. School
of Xedi&ru,i
T HAS often been reported that the incidence of eclampsia in the State of Maryland is unusually high. These reports were principally based upon the work of Williams1 in 1912. This study has been undertaken to find if this assumption is still justified, am1 at the same time to investigate other aspects regarding the disease in this State. Medical literature provides considerable data on eclampsia. There are wide variations in incidence and mortality throughout the world. Tn the United States both incidence and mortality are about the average ; however, it is estimated’ that today eclampsia and the toxemia associated with it accounts for 30 per cent of the approximately 15,000 annual maternal deaths in this country. Therefore, as Bill3 states, eclampsia still remains our greatest problem iu obstetrics. Table I gives a brief statistical review of eclampsia ill various regions of the world. It is mostly based upon hospitalization rather than on the total number of births occurring in the given area, ant1 probably accounts for the wide variatiou. Our period of study includes the five years from 1931.through 1935. It is difficult to obtain complete information about eclampsia in Rlaryland as no report of the disease is made to the Health Department except when death occurs. As most cases of eclampsia in Maryland are hospitalized, it was felt that by examining the records of all hospitals in t,his state we could obtain nearly the complete incidence of eclampsia which occurred in pregnancies for the period. A questio.nnaire was made up and sent to each of the 3-2hospitals taking care of maternity eases. One of t,he authors personally visited 14 of these hospitals and examined their records, while 18 others responded satisfactorily to the questionnaire. Two small hospitals in outlying SPmely settled districts failed to respond; however, it is our impresI
YEAR AUTHOR -1912 William@ 1922 McPherson4 1922 Cruikshanks 1926 Greenhills 1926 Davis? 1927 Rices 1930 GyllensvLdo 1930 Kinglo 1930 Upshawl 1930 Stapletonla 1932 Hoffstromla 1932 Gerrardid 1933 Gibson15 1934 Hauchlc 1934 Binderlr 1936 Kimbroughl8 1937 Reese and Peyton *N. R., Not reported.
Baltimore New York Glasgow Chicago New York New York Stockholm Peiping Georgia Calcutta Finland England Australia Denmark New Jersey Philadelphia Maryland
REQION
= %
%
E
%
%
PRIMIMULTIANTE INTRA DENCES GRAVIDA DBAVIDA PARTUM PARTUN 1.00 60.0 40.0 55.5 T _I. 7 65.6 20.0 0.75 (il.4 35.6 _--_- $> 5 _----3.44 65.1 34.9 0.28 73.1 26.9 50.0 20.5 0.57 N.R. N.R. 58.0 13.4 0.53 58.0 42.0 50.0 23.0 0.60 N.R. N.R. N.R. N.R. 60.0 j 30.0 1.50 75.0 25.0 _---- 84.0 -----1.50 GS.0 32.0 5.40 18.5 18.0 75.8 51.5 N.R. N.R. 0.95 80.0 20.0 1.09 72.0 28.0 43.0 29.0 20.0 0.61 68.1 31.9 59.0 0.17 N.R. N.R. N.R. N.R. 31.7 0.70 N.R. N.R. 31.7 20.0 65.2 9.8 0.34 80.0 29.5 0.20 70.5 54.6 - "5.4
% INCI-
RESUME OF CASES REVIEWED IN LITERATURE*
VLJMBERNUMBEI OF OF LABORS ______ CASES 11,000 110 890 120,000 814 23,630 29,557 152,248 8;; 42,070 222 48,053 282 2,256 33 152 9,730 1,200 65 25,260 240 9,116 100 101 16,903 737,701 1,286 18,942 123 12,601 43 146,652 299
TABLE I.
%
POST PARTUM 21.8 15.0 21.5 29.5 28.6 27.0 N.R. 10.0 16.0 6.2 N.R. 18.0 21.0 N.R. 36.6 25.0 20.0
%
2 15:5 11.4 13.9 20.4
22.8 17.4 22.4 7.7 23.0 21.0 7.8 12.1 21.0 22.0 15.9
NATERNAI MORTALITl
% 44.5 25.4 36.6 27.7 34.0 45.0 31.0 44.0 34.0 N.R. 29.8 N.R. 36.0 34.1 44.3 28.0 31.0
FETAL MORTALITY
k
E
L2 % T m" 2 0 z. .
132
ARfI?RICAX
.JO~:RKAII
sion t,hat t.hey do litde ilnimprwtanl. nffectillp
OF
OBSTETR~ICS
or ILO obstetrics the final fgnrrs
AND
CYNECOLOGY
and their fa.ilures very little.
are relat.ivel!
Uuring t,he five-year period, lXH,NJS live biri.hs and 8,7-l:! stillbirths were recorded in the Htatc.~~ If corrrc~tion is m:ttl~ for pets of twins (1.650) and triplets (914). the numht~r of pregnanc*ic~s rq~rc~c*nted by thetie births and stillbirths would hi .146,6:?2. Among these thtlrc> were 299 cases of eCl:tmpsia or an incidence of 1 case in 490 pregnancies (0.20 prr i.cnt ). Of thr 299 raws, 69 occurred in 1931, 50 in 1932, T-4 in 19X, 47 in 19:X, ant1 59 in 193X1. ‘l%re is no significant variation in the numhrr of PRS~E appearing yc~l.rl~-.
hl illr, 1lre.uent serif, 70.5 11,‘~ ~nll. wert’ ptimigravidas and 29.5 per cent multigravi(l:ts (‘l’ahle 1 ). Of thr 146,6S pregnancies, 4ti,428 were primigmvidss and IOO,~~4 WCW Irlllli,igriLVi(las. ‘l’l~ incidencae of eclampsia for primigravidas t*hrrefore, wns one in UYI pregnancies or 0.45 per cent ant1 for multigrnvidas one in. l,IB$j or 0.09 leer cent. These results bear out the well-recognized fact that eclampsia is much more prevalent in tlx primigravidaa.
The lxrgc nc~gro population of Naryland made it possible for problem on a racial basis. One hundred and seven of the 33,155 women had eclampsia or one in 310 (0.X per cent) as compared to per centj in the white race. The prevalence of eclampsia in agreement with t,he findings of Tlpshaw 11 in Georgia who reported incidence of 1.5 per npnt, and it, ~,n partly be explained by the care, age, and poor living conditions of these people. Table II comparison subdivided according to multiparous and primiparous
--.__.
.-__I
WHITE PREGNANCIES
Primigravidas Multigravidas Total ______--.-.-~
us to study the colored pregnant one in 591 (0.17 the negro is in an even greater lack of prenatal gives a further pregnancies.
--~--
CASES - --_--8
37,724 75,77:: 113,497
$y:;;;
--..TYI’E
i
COLORED PREGNANCIES
CASES
0.86 0.13 0.32
..-.- .~ ~~~_--..--~.L___:---Ok’
INCIDENCE PER CENT
ECI,~ADIPSlA
One hundred and sixty-four or 54 per cent of the cases occurred ante partum, 75 or 25.4 per cent intra partum, and 60 or 20 per cent post partum. These figures coincide with most authors and very closely approximate the series studied by Wil1iams.l The percentage of cases appearing ante partum and intra partum in the primigravidas and the multigravidas are about the same. Post partum eolampsia is 7 per cent more common in the multigravidaa (Table III). TABLE
III.
Drrrsro~
ANTE
PARTUM
OF CASES
AS T O TYPE
AND
PARITY
--
Primigravidas Ml&igWi&SS Combined
--
INTRA
PARTUBf
POST
PARTUM
NO. OF CASES
PER CENT OF TOTAL
NO. OF CASES
PERCENT OF TOTAL
NQ. OF CASES
PER CENT OF TOTAL
118 46 164
55.8 52.2 54.6
55 20 75
26.0 22.7 25.4
38
18.2 25.1 20.0
-
REESE-PEYTON: MULTIPLE
133
ECLAMPSIA
PREX~NANCY
AND
ECLAMPSIA
Crowem and others6 11, 1% 18 report that from 4 to 7 per cent of their cases of eelampsia were associated with multiple pregnancy. In this series there were 9 multiple pregnancies or one out of every 30 (3 per cent), and since the normal incidence of twin pregnancy is usually given as one in 80, it could be assumed that eelampsia is 21/s times as prevalent here as in single pregnancies. RECURRINQ
ECLAMPSIA
In recent years more has been written about the recurrence of eclampsia. Peckham20 reports that at Hopkins 4 per cent of all eclamptic patients suffer from a second attack in a future gestation; Young21 in Edinburgh, cites various authors’ findings as being from 1.5 to 2.8 per cent. Schmeckel finds that in Dresden 40 per cent of eclamptic patients have symptoms and 20 per cent develop convulsions in future pregnancies. The latter author states that in a recurring c,ase the disease is benign. We found eclampsia recurring in 5 cases. Four of the cases were of the severe type and 3 patients died, making the mortality 60 per cent. We believe the physician should consider the pregnant woman with a history of eclampsia seriously. If a second attack has occurred, we recommend prevention of future pregnancies, and if she becomes gravid for the third time, and shows evidence of severe kidney dysfunction, we rec.ommend abortion. SEVERITY
OF ECL'AMPSIA
Each case of eclampsia was designated severe or mild depending upon the number of convulsions or coma. Ten or more convulsions or prolonged coma classified a case as severe. One hundred and nineteen or 40 per cent of all the cases were of the severe type, and ante-partum eclampsia appeared to be the most severe. The cases are compared according to severity and parity in Table IV. IV.
TABLE
SEVERE ANTE
AKD
PARTUSf
MILD
GUES INTRA
ACCORDIKG PARTUM
TO PARITY POST
ILND
PARTIJM
TYPE TOTAL
Primigravidas Multigravidas Combined TREATMENT Probably no other obstetric complication has been given a.s much consideration as the handling of the eclamptic patient. There have been for the past twenty years two distinct schools of treatment: conservative and radical, the former gaining in followers as time goes on, and showing upon the whole decidedly better results for the mother, am1 apparently fairly good for the baby. The patients in NUMBER
NUMBER 60
OF
CASES
CASES TREATED RADICALLY
CONSERVATIVELY BY YEAR
AND
134
ILMEXICAN
JOURNAL
OF
OBSTETRICS
AND
GYNEC’OLOGY
tllis study were treated
in both ways, the conservative met,hod increasing as timcb went on. So far as could be determined there were few, if any, variations from the accepted methods of sedation, rest, etc., in thoscb CHSCR so handled. One huntfrrcl and right or -15.7 1~ cent of the 239 patients having anteand intra-parlultl cc~lampsia wert: treated radically, the remaining I:: 1 cdonservativelp. Primigravitls~ were more often treated by hastening the terlrtimttion of pregIl:tnvy tlliln nlultigravidas. the perrrnt,:tgr,king -17 :Iml 20 kx*r <*csnt, rcqtsctivrly.
111 comparily tkltimc)ret the 011lv large c,itJr iu the Stat.c, with the rest of the state. alt jllteresting fiiicliii, 03was obtained. Table \’ shows the number of patients treated in Baltimore as compal*ed t,o the rest of the state and the method of treatmellt, for the patients having eclampsia before delivery. Twentyseven per cent of the patients were treated radically in Baltimore in contrast to 65 per cent treated in the same way in the rest of the slate. TABLE v.
*utside
LOCATION of BaItimore
OF Tn&wnrm~ ~NTRA-PARTUM _I_-~ --.---.-.-_
/ -,---
--
I 3 1 _~__.
~~~ ~_
JIATERNAL
FOR ANTE-
AsD
Ecr,u~s~a __-
h-0. OF (‘ASES /----RADICAL ---~---~~~--~~ ..-108
/
Baltimore ~~__-...--~~~.-~~-.
no lAO~%T~O~
TYI'E
--_. 5i .-----.
‘9--~.I( ..-_.
TREAT~;G,SER,AT,:-~~ ~/-2 ___37
I
,
--
94
blORTALITY
Sixty-one of the 299 patients died giving a mortality of 20.4 per cent. This mortality rate is higher than in certain regions in the United States but is 10.5 pel cent less than the report of 1912 for Baltimore.1 The number of deaths in this study represent 8.3 per cent of the total 737 maternal deaths in the States for the period.24 We have accounted for 61 of the 70 deaths reported as eclampsis on death certificates. Forty-three or 71 per caent of the deaths were in the ante-partum eclampti(s paCents while 17 per eent and 12 per cent were in the intraand post-partum cases, respectively. The mortality rates are shown in Tahle VT; post-partum eelampsia in multigravidas appear to be most fatal. TABLE
VI.
MORTALITY
RATES
FOR THE -
GROUP
ANTE
CASES
AS TO PARITY II__---
AND
TYPE _I_ ____ TOTAL
PARTUM
Primigravidas Multigravidas Combined Surgical four per
14%
28% 20% I_---
treatment cent of all VII.
TABLE
increased patients
the treated
REGIONAL
maternal radically
MORTALITY
I>OCALITY
of Bal-
mortality died, in OF CASES
ny
tremendously. contrast to
Thirty13 per cent
TREATMENT
TREATMENT" ~~
I-.
Outside
SURQICAI, NO. I'ASES ___-_-
XEDICAL
--___MORTALITY -___
71.
36%
NO. CASES
NO. DEaTHS
40
7
- .__-!vXORTALITY
27% 10% 12% - ___--
aPost-partum
-...
--- -
eclampsia
w&s
not
included
in
these
flgwes.
REESE-PEYTON
:
mortality for those receiving conservative therapy. of cases as to treatment in Baltimore and the rest mortalities. FETAL
135
ECLAMPSIA
Table VII of the State
reveals the analysis with their respective
MORTALITY
Ninety-three of the 308 babies (includes 9 sets of twins) were stillborn or died within seventy-two hours. This gives a total fetal mortality of 30.2 per cent. Only two babies whose mothers had postpartum eclampsia died, giving a fetal mortality of 36 per cent for those patients developing eclampsia prior to delivery. This figure is much lower than the average for the world, and approximates the record of clinics reporting the lowest mortality rates. Prompt surgical treatment of the mother was followed by a 17 per cent fetal mortality, while those patients treated conservatively showed a 43 per cent fetal mortality indicating that the risk for the baby is considerably greater with medical therapy. PRENATAL
CARE
Prenatal care means considerably more than an occasional visit to a physician. There are many grades of care and only a small minority of patients receive adequate care. Grade 1 (a) as described in “Standards of Prenatal Care ” (Children’s Bureau Publication No. 153) is the desired type to give: This is described as follows: ‘ll. A careful history, medical, surgical, gynecologic, and obstetric; (2) a complete physical examination, including the examination of heart, lungs, and abdomen; (3) pelvic measurements, both internal and external; (4) the taking of blood for a Wassermann reaction; (5) minute instructions in the hygiene of pregnancy; and (6) visits to a physician at least once a month during the first six months, then oftener as indicated. The first visit must take place not later than the end of the second month. At each of the visits the patient’s general condition is to be investigated : blood pressure, urinalysis, pulse, and temperature recorded; weight of the patient taken if possible; abdominal examination made, and the height of the fundus determined. ’’ It was impossible in this series to determine the grade of prenatal care each patient received. One hundred and sixty-one or 54 per cent received no care whatThe remaining 46 per cent made one or more visits to a physician. The soever. Care of the latter was far from adequate as determined in a detailed study of 50 Of this number only 5 patients received adequate of these 299 cases of eclampsia. Of the 128 patients noted as having received prenatal care as prescribed above. prenatal care, 8 died, giving a mortality of 0.7 per cent in contrast to a mortality of 33 per cent for those that received no prenatal care. SUMMARY
1. the
A
general
CONCLUSIONS
study of eclampsia for has been made. table of eclampsia in various
statistical
State of Maryland
AND
a five-year
period
in
2. A comparative clinics and countries has been presented. 3. The incidence of eclampsia in the general population of Maryland ia 1 in 490, or 20 per cent in contrast to a previous report of 1 per cent for pregnancies given hospitalization. 4. Eclampsia is five times as prevalent in the primigravidas as in multigravidas. 5. The negro population of Maryland showed an incidence of 1 in 310 or 32 per cent. 6. Eclampsia is two and one-half times more prevalent in multiple pregnancy.
136
AMERICAN
JOURNAL
OF
O’BSTETRICS
AND
GYNECOLOGY
7. Recurring eclampsia is severe and carries a high mortality. 8. Ante-parturn eclampsia is the mosi- seyew type. 9. Forty-six l)er cent of the patient;s suft’rr%g from eclampxia before delivery were treated radicall>v. 10. The total maternal mortality was 20.4 l)er veut. 31.. Post-partum eclampsia in the multigravitla is most fatal wit,h a mortality of 32 per cent. 12. Cases handled conservatively had a mortality of 12 per cent ill contrast to 34 per cent for those treated radically. 13. The total fetal mortality was 30.2 per (wit and the risk for the baby is greater if mother receives conservative treatment. 1.4. The desired grade of pi.enatal cart is outlined. 15. Piftjy-four per wut of the patielrts rewivtt no prenatal care. Very few receive adequatIe care. 16. Early detection antI coni.rol of the preeclamptic is the means of attacking eclampsia. 17. Roth incidence a11clmortality of eelampsia are diminished by adequate prenatal care. and
The authors desire tu thank the Ha18timore City Health
the various Department
hospitals for their cooperation in this for the general statistics furnished.
IlEFI!xIES~‘I~“;
study
.,
(1)
lViZZkm.s, J. Whitridge: J-. .k M. .1. 88: 4-49 1927. (2 ) Report of American Commit;teeon Maternal Welfare, J. ’ >I. M. A. 104: 170::, 1935. (3) Bill, A. A.: Ax J. OBST. & GYNW. 23: 115, 1932. (-1) ,IfcPhmon, ROSS: Ibid. 4: 50, 1922. (5) Cruickshank, J. X. : Medical Resrarcll Council Report, No. 117, 1927. (6) Greenhill, J. P.: J. A. M. A. 87: 228, 1926. (7) l)nt%~, ‘-1. B., mnd Hapray, .J. A.: .T. A. M. -4.87: 233! 1926. (8) Rice, F. W.: New York State J. Med. 27: 1,1927. (9) Gylls~asviird, N. : Ibld. 9: 221, 1930. (10) H&ng, C.: Nat. Med. J. China.16: 653,193O. (11) Upshaw, C. B.: South. M. J. 23: 388, 1930. (12) Stapleton, G.: Indian M. Gaz. 65: 132, 1930. (13) Hoff&ram, E. A.: Acta obst. et gynec. Scandinav. 12: 351, 1932. (14) Gerrard, E. A.: Lancet 2: 782, 1932. (1.5) Gibson, A. J.: M. J. Australia 2: 843, 1933. (16) Hmch, E.: Acta ohst. et gynec. Seandinav. 14: 425, 1934. (17) Binder, J.: AM. J. 0~s~. & G~xw. 27: 51, 1931. (18) Kin~broqqh, B. A.: AM. J. OBST. & GYNEC. 32: 415, 1936. (1.9) Crozue, E.: Edinburgh M. J. 29: 49, 1928-1929. (20) Peckham, C. H.: ,Johns Hopkins Hosp. Bull. 45: 176, 1929. (21) Young, d. : Proc. Royal Hoc. Med. 22: 26, 1929. (22) Lazcn: Zeutralbl. f. Gynak. 52: 1792, 1928. (23) SchmeckPZ, d.: Zentralbl. f. bynak. 53: 2105, 1929. (24) Annual Report Maryland State Dept. of Health, 1935. (25) Maternal Mortality in 15 States, Children’s Bureau Publication, pu’o. 223. (26) Annual Birth Statistics, TJ. 6. Bureau of Census, 1931-34, and Special Report, Summary of Vital Statistics, Maryland, 19.15.
Goedel, R.: 651,
Roentgen
Ray
Treatment
of Puergeral
Mastitis,
Strahlentherapie
58:
193i.
The treatment of choice in cases of acme mastitis is roentgen ray therapy, applied early and repeated at definite intervals. In this way operation may be avoided in almost 100 per cent of cases, recurrences are prevented and nursing is maintained. J. 1'. GREENHILL.
:\ FIVE-YEAR J.
STUDY
MORRIS
&ESE,
OF ECLAMPSIA
IN NARYLAND
M.D.,
%ID.,
FR,ANK W. PEYTON, (Prom
the L)eprtment
of
Obstetrics,
IZALTIMORE,
M.D., LAFAYETTE, University of Illaryland,
AXD
Im. School
of Xedi&ru,i
T HAS often been reported that the incidence of eclampsia in the State of Maryland is unusually high. These reports were principally based upon the work of Williams1 in 1912. This study has been undertaken to find if this assumption is still justified, am1 at the same time to investigate other aspects regarding the disease in this State. Medical literature provides considerable data on eclampsia. There are wide variations in incidence and mortality throughout the world. Tn the United States both incidence and mortality are about the average ; however, it is estimated’ that today eclampsia and the toxemia associated with it accounts for 30 per cent of the approximately 15,000 annual maternal deaths in this country. Therefore, as Bill3 states, eclampsia still remains our greatest problem iu obstetrics. Table I gives a brief statistical review of eclampsia ill various regions of the world. It is mostly based upon hospitalization rather than on the total number of births occurring in the given area, ant1 probably accounts for the wide variatiou. Our period of study includes the five years from 1931.through 1935. It is difficult to obtain complete information about eclampsia in Rlaryland as no report of the disease is made to the Health Department except when death occurs. As most cases of eclampsia in Maryland are hospitalized, it was felt that by examining the records of all hospitals in t,his state we could obtain nearly the complete incidence of eclampsia which occurred in pregnancies for the period. A questio.nnaire was made up and sent to each of the 3-2hospitals taking care of maternity eases. One of t,he authors personally visited 14 of these hospitals and examined their records, while 18 others responded satisfactorily to the questionnaire. Two small hospitals in outlying SPmely settled districts failed to respond; however, it is our impresI
YEAR AUTHOR -1912 William@ 1922 McPherson4 1922 Cruikshanks 1926 Greenhills 1926 Davis? 1927 Rices 1930 GyllensvLdo 1930 Kinglo 1930 Upshawl 1930 Stapletonla 1932 Hoffstromla 1932 Gerrardid 1933 Gibson15 1934 Hauchlc 1934 Binderlr 1936 Kimbroughl8 1937 Reese and Peyton *N. R., Not reported.
Baltimore New York Glasgow Chicago New York New York Stockholm Peiping Georgia Calcutta Finland England Australia Denmark New Jersey Philadelphia Maryland
REQION
= %
%
E
%
%
PRIMIMULTIANTE INTRA DENCES GRAVIDA DBAVIDA PARTUM PARTUN 1.00 60.0 40.0 55.5 T _I. 7 65.6 20.0 0.75 (il.4 35.6 _--_- $> 5 _----3.44 65.1 34.9 0.28 73.1 26.9 50.0 20.5 0.57 N.R. N.R. 58.0 13.4 0.53 58.0 42.0 50.0 23.0 0.60 N.R. N.R. N.R. N.R. 60.0 j 30.0 1.50 75.0 25.0 _---- 84.0 -----1.50 GS.0 32.0 5.40 18.5 18.0 75.8 51.5 N.R. N.R. 0.95 80.0 20.0 1.09 72.0 28.0 43.0 29.0 20.0 0.61 68.1 31.9 59.0 0.17 N.R. N.R. N.R. N.R. 31.7 0.70 N.R. N.R. 31.7 20.0 65.2 9.8 0.34 80.0 29.5 0.20 70.5 54.6 - "5.4
% INCI-
RESUME OF CASES REVIEWED IN LITERATURE*
VLJMBERNUMBEI OF OF LABORS ______ CASES 11,000 110 890 120,000 814 23,630 29,557 152,248 8;; 42,070 222 48,053 282 2,256 33 152 9,730 1,200 65 25,260 240 9,116 100 101 16,903 737,701 1,286 18,942 123 12,601 43 146,652 299
TABLE I.
%
POST PARTUM 21.8 15.0 21.5 29.5 28.6 27.0 N.R. 10.0 16.0 6.2 N.R. 18.0 21.0 N.R. 36.6 25.0 20.0
%
2 15:5 11.4 13.9 20.4
22.8 17.4 22.4 7.7 23.0 21.0 7.8 12.1 21.0 22.0 15.9
NATERNAI MORTALITl
% 44.5 25.4 36.6 27.7 34.0 45.0 31.0 44.0 34.0 N.R. 29.8 N.R. 36.0 34.1 44.3 28.0 31.0
FETAL MORTALITY
k
E
L2 % T m" 2 0 z. .
132
ARfI?RICAX
.JO~:RKAII
sion t,hat t.hey do litde ilnimprwtanl. nffectillp
OF
OBSTETR~ICS
or ILO obstetrics the final fgnrrs
AND
CYNECOLOGY
and their fa.ilures very little.
are relat.ivel!
Uuring t,he five-year period, lXH,NJS live biri.hs and 8,7-l:! stillbirths were recorded in the Htatc.~~ If corrrc~tion is m:ttl~ for pets of twins (1.650) and triplets (914). the numht~r of pregnanc*ic~s rq~rc~c*nted by thetie births and stillbirths would hi .146,6:?2. Among these thtlrc> were 299 cases of eCl:tmpsia or an incidence of 1 case in 490 pregnancies (0.20 prr i.cnt ). Of thr 299 raws, 69 occurred in 1931, 50 in 1932, T-4 in 19X, 47 in 19:X, ant1 59 in 193X1. ‘l%re is no significant variation in the numhrr of PRS~E appearing yc~l.rl~-.
hl illr, 1lre.uent serif, 70.5 11,‘~ ~nll. wert’ ptimigravidas and 29.5 per cent multigravi(l:ts (‘l’ahle 1 ). Of thr 146,6S pregnancies, 4ti,428 were primigmvidss and IOO,~~4 WCW Irlllli,igriLVi(las. ‘l’l~ incidencae of eclampsia for primigravidas t*hrrefore, wns one in UYI pregnancies or 0.45 per cent ant1 for multigrnvidas one in. l,IB$j or 0.09 leer cent. These results bear out the well-recognized fact that eclampsia is much more prevalent in tlx primigravidaa.
The lxrgc nc~gro population of Naryland made it possible for problem on a racial basis. One hundred and seven of the 33,155 women had eclampsia or one in 310 (0.X per cent) as compared to per centj in the white race. The prevalence of eclampsia in agreement with t,he findings of Tlpshaw 11 in Georgia who reported incidence of 1.5 per npnt, and it, ~,n partly be explained by the care, age, and poor living conditions of these people. Table II comparison subdivided according to multiparous and primiparous
--.__.
.-__I
WHITE PREGNANCIES
Primigravidas Multigravidas Total ______--.-.-~
us to study the colored pregnant one in 591 (0.17 the negro is in an even greater lack of prenatal gives a further pregnancies.
--~--
CASES - --_--8
37,724 75,77:: 113,497
$y:;;;
--..TYI’E
i
COLORED PREGNANCIES
CASES
0.86 0.13 0.32
..-.- .~ ~~~_--..--~.L___:---Ok’
INCIDENCE PER CENT
ECI,~ADIPSlA
One hundred and sixty-four or 54 per cent of the cases occurred ante partum, 75 or 25.4 per cent intra partum, and 60 or 20 per cent post partum. These figures coincide with most authors and very closely approximate the series studied by Wil1iams.l The percentage of cases appearing ante partum and intra partum in the primigravidas and the multigravidas are about the same. Post partum eolampsia is 7 per cent more common in the multigravidaa (Table III). TABLE
III.
Drrrsro~
ANTE
PARTUM
OF CASES
AS T O TYPE
AND
PARITY
--
Primigravidas Ml&igWi&SS Combined
--
INTRA
PARTUBf
POST
PARTUM
NO. OF CASES
PER CENT OF TOTAL
NO. OF CASES
PERCENT OF TOTAL
NQ. OF CASES
PER CENT OF TOTAL
118 46 164
55.8 52.2 54.6
55 20 75
26.0 22.7 25.4
38
18.2 25.1 20.0
-
REESE-PEYTON: MULTIPLE
133
ECLAMPSIA
PREX~NANCY
AND
ECLAMPSIA
Crowem and others6 11, 1% 18 report that from 4 to 7 per cent of their cases of eelampsia were associated with multiple pregnancy. In this series there were 9 multiple pregnancies or one out of every 30 (3 per cent), and since the normal incidence of twin pregnancy is usually given as one in 80, it could be assumed that eelampsia is 21/s times as prevalent here as in single pregnancies. RECURRINQ
ECLAMPSIA
In recent years more has been written about the recurrence of eclampsia. Peckham20 reports that at Hopkins 4 per cent of all eclamptic patients suffer from a second attack in a future gestation; Young21 in Edinburgh, cites various authors’ findings as being from 1.5 to 2.8 per cent. Schmeckel finds that in Dresden 40 per cent of eclamptic patients have symptoms and 20 per cent develop convulsions in future pregnancies. The latter author states that in a recurring c,ase the disease is benign. We found eclampsia recurring in 5 cases. Four of the cases were of the severe type and 3 patients died, making the mortality 60 per cent. We believe the physician should consider the pregnant woman with a history of eclampsia seriously. If a second attack has occurred, we recommend prevention of future pregnancies, and if she becomes gravid for the third time, and shows evidence of severe kidney dysfunction, we rec.ommend abortion. SEVERITY
OF ECL'AMPSIA
Each case of eclampsia was designated severe or mild depending upon the number of convulsions or coma. Ten or more convulsions or prolonged coma classified a case as severe. One hundred and nineteen or 40 per cent of all the cases were of the severe type, and ante-partum eclampsia appeared to be the most severe. The cases are compared according to severity and parity in Table IV. IV.
TABLE
SEVERE ANTE
AKD
PARTUSf
MILD
GUES INTRA
ACCORDIKG PARTUM
TO PARITY POST
ILND
PARTIJM
TYPE TOTAL
Primigravidas Multigravidas Combined TREATMENT Probably no other obstetric complication has been given a.s much consideration as the handling of the eclamptic patient. There have been for the past twenty years two distinct schools of treatment: conservative and radical, the former gaining in followers as time goes on, and showing upon the whole decidedly better results for the mother, am1 apparently fairly good for the baby. The patients in NUMBER
NUMBER 60
OF
CASES
CASES TREATED RADICALLY
CONSERVATIVELY BY YEAR
AND
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ILMEXICAN
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tllis study were treated
in both ways, the conservative met,hod increasing as timcb went on. So far as could be determined there were few, if any, variations from the accepted methods of sedation, rest, etc., in thoscb CHSCR so handled. One huntfrrcl and right or -15.7 1~ cent of the 239 patients having anteand intra-parlultl cc~lampsia wert: treated radically, the remaining I:: 1 cdonservativelp. Primigravitls~ were more often treated by hastening the terlrtimttion of pregIl:tnvy tlliln nlultigravidas. the perrrnt,:tgr,king -17 :Iml 20 kx*r <*csnt, rcqtsctivrly.
111 comparily tkltimc)ret the 011lv large c,itJr iu the Stat.c, with the rest of the state. alt jllteresting fiiicliii, 03was obtained. Table \’ shows the number of patients treated in Baltimore as compal*ed t,o the rest of the state and the method of treatmellt, for the patients having eclampsia before delivery. Twentyseven per cent of the patients were treated radically in Baltimore in contrast to 65 per cent treated in the same way in the rest of the slate. TABLE v.
*utside
LOCATION of BaItimore
OF Tn&wnrm~ ~NTRA-PARTUM _I_-~ --.---.-.-_
/ -,---
--
I 3 1 _~__.
~~~ ~_
JIATERNAL
FOR ANTE-
AsD
Ecr,u~s~a __-
h-0. OF (‘ASES /----RADICAL ---~---~~~--~~ ..-108
/
Baltimore ~~__-...--~~~.-~~-.
no lAO~%T~O~
TYI'E
--_. 5i .-----.
‘9--~.I( ..-_.
TREAT~;G,SER,AT,:-~~ ~/-2 ___37
I
,
--
94
blORTALITY
Sixty-one of the 299 patients died giving a mortality of 20.4 per cent. This mortality rate is higher than in certain regions in the United States but is 10.5 pel cent less than the report of 1912 for Baltimore.1 The number of deaths in this study represent 8.3 per cent of the total 737 maternal deaths in the States for the period.24 We have accounted for 61 of the 70 deaths reported as eclampsis on death certificates. Forty-three or 71 per caent of the deaths were in the ante-partum eclampti(s paCents while 17 per eent and 12 per cent were in the intraand post-partum cases, respectively. The mortality rates are shown in Tahle VT; post-partum eelampsia in multigravidas appear to be most fatal. TABLE
VI.
MORTALITY
RATES
FOR THE -
GROUP
ANTE
CASES
AS TO PARITY II__---
AND
TYPE _I_ ____ TOTAL
PARTUM
Primigravidas Multigravidas Combined Surgical four per
14%
28% 20% I_---
treatment cent of all VII.
TABLE
increased patients
the treated
REGIONAL
maternal radically
MORTALITY
I>OCALITY
of Bal-
mortality died, in OF CASES
ny
tremendously. contrast to
Thirty13 per cent
TREATMENT
TREATMENT" ~~
I-.
Outside
SURQICAI, NO. I'ASES ___-_-
XEDICAL
--___MORTALITY -___
71.
36%
NO. CASES
NO. DEaTHS
40
7
- .__-!vXORTALITY
27% 10% 12% - ___--
aPost-partum
-...
--- -
eclampsia
w&s
not
included
in
these
flgwes.
REESE-PEYTON
:
mortality for those receiving conservative therapy. of cases as to treatment in Baltimore and the rest mortalities. FETAL
135
ECLAMPSIA
Table VII of the State
reveals the analysis with their respective
MORTALITY
Ninety-three of the 308 babies (includes 9 sets of twins) were stillborn or died within seventy-two hours. This gives a total fetal mortality of 30.2 per cent. Only two babies whose mothers had postpartum eclampsia died, giving a fetal mortality of 36 per cent for those patients developing eclampsia prior to delivery. This figure is much lower than the average for the world, and approximates the record of clinics reporting the lowest mortality rates. Prompt surgical treatment of the mother was followed by a 17 per cent fetal mortality, while those patients treated conservatively showed a 43 per cent fetal mortality indicating that the risk for the baby is considerably greater with medical therapy. PRENATAL
CARE
Prenatal care means considerably more than an occasional visit to a physician. There are many grades of care and only a small minority of patients receive adequate care. Grade 1 (a) as described in “Standards of Prenatal Care ” (Children’s Bureau Publication No. 153) is the desired type to give: This is described as follows: ‘ll. A careful history, medical, surgical, gynecologic, and obstetric; (2) a complete physical examination, including the examination of heart, lungs, and abdomen; (3) pelvic measurements, both internal and external; (4) the taking of blood for a Wassermann reaction; (5) minute instructions in the hygiene of pregnancy; and (6) visits to a physician at least once a month during the first six months, then oftener as indicated. The first visit must take place not later than the end of the second month. At each of the visits the patient’s general condition is to be investigated : blood pressure, urinalysis, pulse, and temperature recorded; weight of the patient taken if possible; abdominal examination made, and the height of the fundus determined. ’’ It was impossible in this series to determine the grade of prenatal care each patient received. One hundred and sixty-one or 54 per cent received no care whatThe remaining 46 per cent made one or more visits to a physician. The soever. Care of the latter was far from adequate as determined in a detailed study of 50 Of this number only 5 patients received adequate of these 299 cases of eclampsia. Of the 128 patients noted as having received prenatal care as prescribed above. prenatal care, 8 died, giving a mortality of 0.7 per cent in contrast to a mortality of 33 per cent for those that received no prenatal care. SUMMARY
1. the
A
general
CONCLUSIONS
study of eclampsia for has been made. table of eclampsia in various
statistical
State of Maryland
AND
a five-year
period
in
2. A comparative clinics and countries has been presented. 3. The incidence of eclampsia in the general population of Maryland ia 1 in 490, or 20 per cent in contrast to a previous report of 1 per cent for pregnancies given hospitalization. 4. Eclampsia is five times as prevalent in the primigravidas as in multigravidas. 5. The negro population of Maryland showed an incidence of 1 in 310 or 32 per cent. 6. Eclampsia is two and one-half times more prevalent in multiple pregnancy.
136
AMERICAN
JOURNAL
OF
O’BSTETRICS
AND
GYNECOLOGY
7. Recurring eclampsia is severe and carries a high mortality. 8. Ante-parturn eclampsia is the mosi- seyew type. 9. Forty-six l)er cent of the patient;s suft’rr%g from eclampxia before delivery were treated radicall>v. 10. The total maternal mortality was 20.4 l)er veut. 31.. Post-partum eclampsia in the multigravitla is most fatal wit,h a mortality of 32 per cent. 12. Cases handled conservatively had a mortality of 12 per cent ill contrast to 34 per cent for those treated radically. 13. The total fetal mortality was 30.2 per (wit and the risk for the baby is greater if mother receives conservative treatment. 1.4. The desired grade of pi.enatal cart is outlined. 15. Piftjy-four per wut of the patielrts rewivtt no prenatal care. Very few receive adequatIe care. 16. Early detection antI coni.rol of the preeclamptic is the means of attacking eclampsia. 17. Roth incidence a11clmortality of eelampsia are diminished by adequate prenatal care. and
The authors desire tu thank the Ha18timore City Health
the various Department
hospitals for their cooperation in this for the general statistics furnished.
IlEFI!xIES~‘I~“;
study
.,
(1)
lViZZkm.s, J. Whitridge: J-. .k M. .1. 88: 4-49 1927. (2 ) Report of American Commit;teeon Maternal Welfare, J. ’ >I. M. A. 104: 170::, 1935. (3) Bill, A. A.: Ax J. OBST. & GYNW. 23: 115, 1932. (-1) ,IfcPhmon, ROSS: Ibid. 4: 50, 1922. (5) Cruickshank, J. X. : Medical Resrarcll Council Report, No. 117, 1927. (6) Greenhill, J. P.: J. A. M. A. 87: 228, 1926. (7) l)nt%~, ‘-1. B., mnd Hapray, .J. A.: .T. A. M. -4.87: 233! 1926. (8) Rice, F. W.: New York State J. Med. 27: 1,1927. (9) Gylls~asviird, N. : Ibld. 9: 221, 1930. (10) H&ng, C.: Nat. Med. J. China.16: 653,193O. (11) Upshaw, C. B.: South. M. J. 23: 388, 1930. (12) Stapleton, G.: Indian M. Gaz. 65: 132, 1930. (13) Hoff&ram, E. A.: Acta obst. et gynec. Scandinav. 12: 351, 1932. (14) Gerrard, E. A.: Lancet 2: 782, 1932. (1.5) Gibson, A. J.: M. J. Australia 2: 843, 1933. (16) Hmch, E.: Acta ohst. et gynec. Seandinav. 14: 425, 1934. (17) Binder, J.: AM. J. 0~s~. & G~xw. 27: 51, 1931. (18) Kin~broqqh, B. A.: AM. J. OBST. & GYNEC. 32: 415, 1936. (1.9) Crozue, E.: Edinburgh M. J. 29: 49, 1928-1929. (20) Peckham, C. H.: ,Johns Hopkins Hosp. Bull. 45: 176, 1929. (21) Young, d. : Proc. Royal Hoc. Med. 22: 26, 1929. (22) Lazcn: Zeutralbl. f. Gynak. 52: 1792, 1928. (23) SchmeckPZ, d.: Zentralbl. f. bynak. 53: 2105, 1929. (24) Annual Report Maryland State Dept. of Health, 1935. (25) Maternal Mortality in 15 States, Children’s Bureau Publication, pu’o. 223. (26) Annual Birth Statistics, TJ. 6. Bureau of Census, 1931-34, and Special Report, Summary of Vital Statistics, Maryland, 19.15.
Goedel, R.: 651,
Roentgen
Ray
Treatment
of Puergeral
Mastitis,
Strahlentherapie
58:
193i.
The treatment of choice in cases of acme mastitis is roentgen ray therapy, applied early and repeated at definite intervals. In this way operation may be avoided in almost 100 per cent of cases, recurrences are prevented and nursing is maintained. J. 1'. GREENHILL.